Provider Demographics
NPI:1427238062
Name:YACEVICH, ILYA JAIME (MA)
Entity type:Individual
Prefix:
First Name:ILYA
Middle Name:JAIME
Last Name:YACEVICH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1269 BEACON ST
Mailing Address - Street 2:THE TRAUMA CENTER
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-5248
Mailing Address - Country:US
Mailing Address - Phone:617-232-1303
Mailing Address - Fax:
Practice Address - Street 1:1269 BEACON ST
Practice Address - Street 2:THE TRAUMA CENTER
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-5248
Practice Address - Country:US
Practice Address - Phone:617-232-1303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-12
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist